Two or more checked categories indicates high likelihood of sleep apnea.


 Phone Email I prefer not to be contacted

 Male Female

 Yes No

 Yes No

If you snore:


 Slightly louder than breathing Louder than talking As loud as talking Very Loud


 Almost everyday 3-4 times a week 1-2 times a week Never or almost never


 Yes No


 Almost everyday 3-4 times a week 1-2 times a week Never or almost never


 Almost everyday 3-4 times a week 1-2 times a week Never or almost never


 Almost everyday 3-4 times a week 1-2 times a week Never or almost never


 yes No

If yes:


 Almost everyday 3-4 times a week 1-2 times a week 1-2 times a month Never or almost never


 Yes No Not Sure